Mental illness: Not everyone recovers from it

by Mary Zdanowicz

"Recovery from mental illness is possible," wrote the director of one Maine psychiatric hospital, painting a rosy picture of life with schizophrenia. A week after his piece was published, one of his recently released patients stood accused of bludgeoning his mother to death.

William Bruce wasn't afforded that chance at recovery. After Bruce was accused of killing his mother, the hospital director explained why. "In Maine, a client can choose not to be engaged in treatment ... [t]he major issue is when someone does not appear eminently [sic] dangerous and cannot be committed."

This attitude is emblematic of a bizarre tendency by some in the mental health community to bank on an illusion of recovery for everyone, ignoring issues like awareness of illness and violence in the hope that disregarding them will eliminate stigmata.

The problem with that strategy is that it isn't true. And anyone who reads a newspaper knows it.

The mantra is that schizophrenia is not disabling and people who have it are no more violent than the general public. That simple message is more damaging than the one it tries to correct -- that schizophrenia means a life of disability and violence.

A small group of people with mental illnesses are more violent than the general public; those are the ones not taking medication. Failing to acknowledge this -- because of a misguided sense of political correctness or fear of stigmatizing everyone with a mental illness -- keeps everyone from acting to help that small group.

A recent national study clarifies who is at the greatest risk of being dangerous. Schizophrenia patients with "positive symptoms" (paranoid delusions, hearing voices, having imagined superhuman powers) were at least three times more likely to be violent than other schizophrenia patients.

Scientific data like this helps clarify who most needs treatment interventions, reducing stigma for others with mental illnesses -- and saving lives.

The establishment also tends to ignore the science on insight into illness. They talk about "choice," disregarding studies showing some people are unable to choose. The most common cause of nonadherence to treatment is actually not side effects, stigma, or medication cost, but a lack of insight into illness. That can seriously interfere with a patient's ability to weigh meaningfully the consequences of various treatment options.

How does that affect choice? We understand that William Bruce thought the CIA had implanted a device under his skin. How will seeing a psychiatrist help you if the CIA is after you? Building a trusting therapeutic relationship is impossible if a patient imagines his doctor is part of a CIA plot. Medication is needed to combat the delusions.

Maine, like every other state, has a law allowing civil commitment for people who meet strict standards. Sadly, the law is misunderstood even by mental health professionals.

In one news story, William Bruce's father, Robert Bruce, recounted what he said to his wife the night before she was killed: "I can't believe they allow these people out on the streets. ... What do we have to wait for? Do we have to wait for him to hurt somebody or kill somebody before they do something?'"

Too late for the Bruce family, the correct answer is "no." Maine's law does allow intervention before someone is deemed "imminently dangerous," and it is within the scope of the law for the hospital director to make discharge from a psychiatric facility conditional on someone taking medication.

But some mental health professionals assume it is harmful to mandate someone to accept treatment. This is a myth. In one study, individuals in court-mandated community treatment had low levels of perceived coercion, similar to individuals who had never experienced any form of leverage -- they didn't feel "forced," in other words. But those same people reported significantly higher treatment satisfaction than those whose treatment had been voluntary, probably because they didn't get to choose whether to take medication or not.

Maine's laws are weak in that they only allow civil commitment on an inpatient basis -- and there are too few beds to go around. A small pilot program is bringing an outpatient version of civil commitment to Maine -- states with similar programs have seen phenomenal results, reducing arrests, homelessness, and violence for participants. Hopefully that program will soon be available statewide.

Until then, the mental health community must retool its message based on science. Yes, most people with mental illnesses can and do live independent and violence-free lives. But denying the truth about those who remain strips them, and sometimes their caregivers, of the chance to live any kind of life at all.

Mary Zdanowicz is the (forme-ed) executive director of the Treatment Advocacy Center (), a national nonprofit dedicated to removing barriers to treatment of severe mental illnesses.

The Kennebec Journal/Morning Sentinel

July 9, 2006 (Sunday)

Reprinted with permission of the author. All rights reserved.

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